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- Discrimination Intake Questionnaire
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Discrimination Intake Questionnaire

Full Name

All names used in the past

Email

Phone number

Address

Date of Birth

Race

Married?

yes no

Sex

male female nonbinary

Name and number of relative in case we can’t contact you

What is the best way to contact you?

Name of employer at issue

How many employees work for the company approx.?

Address of employer at issue

Provide the name of your supervisor or manager

Start date with employer at issue

End date with employer at issue

Date of Incident

Type of Discrimination

Date of first discriminatory act

Date of last discriminatory act

Please describe in detail the circumstances leading to and surrounding your dispute

What was the last discriminatory act?

Have you filed an EEOC charge?

yes no

If filed an EEOC charge, provide the date filed and EEOC number

Have you received a right to sue notice from the EEOC?

yes no

Job Title

Job Duties

Salary or hourly employee

salary hourly

Did you work overtime?

yes no

Did you work off clock?

yes no

How much were you paid ($) at employer at issue

How many hours worked on a weekly basis?

Fringe benefits: please detail any benefits you received, including but not limited to health, vision, dental, 401k, and/or dependent coverage

Please describe your promotional history with the employer at issue

Please describe your disciplinary history with the employer at issue

If terminated / disciplined, what was the reason stated for the termination / discipline

Prior or current lawsuits: Have you been involved in any prior lawsuit or are currently involved in any lawsuits (including bankruptcy filings)?

If so, please specify the court, case number, subject matter, and final disposition.

Who will testify for you?

Who will testify against you?

Please list all diagnosed medical conditions that relate to your dispute

Please list all medications / prescriptions you currently take that relate to your dispute

Have you been fired from a job?

yes no

Have you been convicted of a crime?

yes no

Have you ever filed bankruptcy?

yes no

Have you ever filed for SSI?

yes no

Have you ever applied for short term/long term disability through employers benefit?

yes no

Did you have health insurance coverage prior to your resignation or termination?

yes no

Have you applied for unemployment as a result of your termination?

yes no

Did you sign an arbitration agreement with this employer?

yes no

Criminal: Please detail any arrests, indictments, and / or convictions

Does your company have an employee handbook?

yes no

Did your employer provide you with an offer letter?

yes no

Did your employer provide you with an employment contract?

yes no

Did you receive performance reviews?

yes no

Did you ever receive any disciplinary notices?

yes no

Did you receive a termination letter or provide a resignation notice?

yes no

Are there any relevant written communications between you, supervisors, HR, or other coworkers?

yes no

Do you have proof of your earnings? (Paystubs, W2, etc)

yes no

Do you have relevant FMLA or Leave of Absence documentation?

yes no

Did you ever file any formal complains with HR or management?

yes no

If you are not working for the employer at issue, have you submitted job applications at new jobs?

yes no

Have you received any rejection letters?

yes no

Have you received any job offers?

yes no

Did you take any personal notes or journals relating to what happened?

yes no

Were you ever placed on a PIP (Performance Improvement Plan)?

yes no

Were you provided with a proposed severance agreement?

yes no

What are your expectations in this lawsuit?

Any other relevant information

If you were referred, please type the name of the person or law firm you were referred by.

By checking the box, you are expressly consenting to receive SMS communication from Carter Law Group. Message and data rates may apply. Message frequency varies. To opt-out, reply STOP. For help, reply HELP.

A fierce, female-owned plaintiffs’ firm with over 20 years of experience taking on catastrophic injury, sexual assault, and workplace discrimination—and winning.

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Discrimination Intake Questionnaire

Contact Us

Amy Carter, Managing Shareholder

Heather Davis, Partner

Hon. Erin Nowell, Partner

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